Week 6 – Rounding out the Breast Cancer Experience

During my final week of immersion, I explored a few areas related to breast cancer that did not involve surgery. I shadowed a medical oncologist who deals with metastatic disease, a geneticist who screens patients who have a strong family history of breast cancer for BRCA1 and BRCA2 gene mutations, and I spent some time in surgical pathology learning how samples are processed during and after surgery. Additionally, I observed an aortic valve replacement procedure which has already been discussed by several other immersion students here.

First, I shadowed Dr. Linda Vahdat, who is my mentor for my clinical project. This was very interesting to me, because it is a very different side of cancer than the one that Dr. Tousimis deals with. While Dr. Tousimis’ patients tend to have a very high survival rate, the patients who end up seeing Dr. Vahdat have much more serious cases of cancer, are on strong medication, and are suffering side effects from the intense chemotherapy. Because she sees her patients on a much more regular basis than Dr. Tousimis (who will see follow up patients once a year after surgery), she develops close relationships with them, and obviously cares very deeply about them. Because of the nature of her practice, she has to routinely deal with losing her patients to this disease. It is a very different mindset, and one that I cannot really comprehend. The cases of her patients going into remission do happen, but much less frequently. As part of her practice, Dr. Vahdat is involved with many clinical trials, and has many, many of her patients involved in them. I was able to sit in on an appointment with a woman who has been battling breast cancer for over fifteen years. Her cancer was stage 4, and had metastasized to her bones, which is fairly common. However, more uncommonly, she has a medium sized tumor on her C2-C3 vertebra. Obviously, this is a very precarious situation. Surgery is out of the question (and in fact is rarely done in metastatic patients). Their goal is to shrink the tumor down to prevent it from growing and metastasizing further. This patient had just started a different chemotherapy drug that greatly affected her both physically (she became extremely tired, lost taste and appetite, etc.) and mentally (depression). For a woman who had before been very optimistic and very much a fighter, this was a radical change in behavior. Dr.Vahdat decided to take her off of the new drug, and all of her other drugs except for Herceptin, which she had never had a problem with, and let her body adjust for a few weeks, to allow her to recover and feel more like herself. Then she is going to try a different drug, Arimidex, which has been on the market for a few years and has shown to be at least moderately effective. The patient was very relieved, because she was clearly very worried about the personality changes she had been undergoing. For someone who has been dealing with this disease for so long, it was amazing to me how determined she was to make herself better. I feel like it can be so easy for women to lose hope at this stage, and she was very concerned about the loss of that determination and optimism.

Second, I was able to briefly shadow a geneticist for a patient consult. The patient had come in to undergo genetic testing not for herself, but out of concern for her daughter, who was considering having children. She was an elderly lady full of spirit and stories, and a very interesting family history. Before the test is performed, the geneticist acquires the most complete family history they can from the patient, going back for as many generations as possible and expanding to as many brothers/sisters/cousins/etc as possible to determine the likelihood of a genetic mutation. This process was very interesting to observe, because the patient would go through each side of the family, listing off the ages that cancer was developed, the age of death, etc. In this patient’s case, both sets of grandparents (or great grandparents?) were killed by the Turkish forces during the Armenian genocide. As a result, her family was spread out across the Middle East, Asia, and the US, different family members having fled and ended up in different areas of the world. After the consult, the geneticist told me how she often finds her job repetitive (she goes through the same explanation almost every time), but that hearing people tell their stories is one of the most interesting parts of her job. Anyway, after collecting the family history, the geneticist explains to the patient that they will only be testing for mutations in two genes (BRCA1 and BRCA2), and that having a mutation does not necessarily mean they will develop cancer, or that their children will have the same mutations. It does, however, increase the risk of both. The genetic testing costs about $3500, and is performed by a lab in Salt Lake City, Utah, which owns the patent on the gene. This patient opted to have the test performed, and her blood was immediately drawn and shipped out for testing.